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Today's Date

Date of Birth (required)

Home Phone

Cell Phone

(1). Have you been under the care of a physician, dermatologist or other medical professional within the past year?
If YES Please Explain

(2) Any recent surgery, including plastic surgery?
If YES Please Explain

(3) Any skin cancer, rashes or any skin problems?
If YES Please Explain

(4) Have you had any of these health conditions in the past or present?

CancerHeadaches (chronic)Hormone imbalanceHepatitisSystemic diseaseHerpesHigh blood pressureFrequent cold soresThyroid ConditionHIV/AIDSImmune disordersLupusDiabetesMental BreakdownHeart problemPhlebitis, blood clots, Poor circulationDepressionBlood clotting abnormalitiesArthritisPsychological treatmentAsthmaInsomniaEczemaPsychological IssuesSkin disease/skin lesionsAny active infectionFever blistersWeight IssuesConstipation Issues

(5). Do you smoke?YesNo

(6). Do you follow a restricted diet? YesNo

(7). Do you follow a regular exercise program? YesNo

(8). What is your stress level? HighMedLow

(9). List any medications you take regularly:

(10). List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:

(11). List your daily consumption of:
Water (Ounces)
Caffeine (Servings)
Alcohol (Servings)

Anything not listed you wish to share with us so we can have a full understanding of your issues?